BH Utilization Management Reviewer (Remote Option)
About the position This position will evaluate medical necessity, appropriateness and efficiency of the services requested for authorization against established criteria adopted by the LME/MCO. Responsibilities • To respond to all requests for authorizations from the provider community with appropriate authorization decision that is guided by medical necessity and clinical guidelines • Services are authorized based on individual need and standardized procedures • Review and authorize initial requests, concurrent requests, urgent requests and retrospective requests • Consulting with providers regarding authorization requests • Consultation with Partners BHM physician regarding requests in which there is a question regarding authorization, enrollee health and safety issues, medication issues, lack of response to services and need for Peer Review when the MHSU Utilization Management Reviewer cannot approve the request for treatment • Development of letters that communicate to enrollees and providers the reason for any adverse decision and offers information regarding the options to appeal any adverse decision Requirements • A Master's Degree in a Human Services field with clinical licensure and two (2) years of post-Master's experience in BH or a Registered Nurse with two (2) years of experience in BH, post RN degree • Must reside in North Carolina • Current unrestricted license with the appropriate professional board of licensure in the state of North Carolina • Licensed to practice as a Registered Nurse in North Carolina by the N. C. Board of Nursing or Independent License in NC as a LCSW, LCMHC, LPA, LMFT Nice-to-haves • Registered Nurse in North Carolina by the N.C. Board of Nursing with experience in psychiatric nursing services Benefits • Annual incentive bonus plan • Medical, dental, and vision insurance with low deductible/low cost health plan • Generous vacation and sick time accrual • 12 paid holidays • State Retirement (pension plan) • 401(k) Plan with employer match • Company paid life and disability insurance • Wellness Programs • Public Service Loan Forgiveness Qualifying Employer Apply tot his job